Health promotion and health education - Wiley Online Library

N U R SI N G T H E O R Y A N D C O N C E PT D E V E L O P M E N T O R A N A L Y SI S

Health promotion and health education: advancing the concepts Dean Whitehead

MSc RN

Senior Lecturer, School of Health Sciences, College of Humanities and Social Sciences, Massey University, Palmerston North, New Zealand

Submitted for publication 10 June 2003 Accepted for publication 7 January 2004

Correspondence: Dean Whitehead, School of Health Sciences, College of Humanities and Social Sciences, Massey University, Private Bag 11 222, Palmerston North, New Zealand. E-mail: [email protected]

W H I T E H E A D D . ( 2 0 0 4 ) Journal of Advanced Nursing 47(3), 311–320 Health promotion and health education: advancing the concepts Background. Health education and health promotion activities are a fundamental requirement for all health professionals. These two paradigms are closely related but are not inter-dependent. Despite this, it is known that many nurses confuse the terms and use them interchangeably. With this in mind, it is necessary to re-conceptualize the terms in an attempt to bring them to a current form of ‘maturity’. Aim. The aim of the paper is to provide an up-to-date analysis of health promotion and health education that serves as a conceptual and operational foundation for clinicians and researchers. Method. A concept analysis following the criterion-based methods described by Morse and her colleagues was applied to the terms health education and health promotion, using generic and nursing-related literature. Results. The conceptual literature on health education is consistent between generic and nursing-related sources. On the contrary, earlier nursing literature on health promotion is now at odds with more recent socio-political and community action models of health promotion, in that it focuses on individualistic and behavioural forms of ‘health promotion’. A significant proportion of later nursing-related literature, however, suggests a maturing of the concept that brings it further in line with a socio-political health promotion agenda. Conclusion. While the theoretical and conceptual literature surrounding health education has remained relatively constant and unchanged over the last decade or so, the same cannot be said for the health promotion literature. The evolving dominance of socio-political action in health promotion has overtaken individualistic and behaviourally-related forms. While the recent nursing literature addresses and acknowledges the place of socio-political activity as the mainstay of health promotion interventions, this is largely from a theoretical stance and is not applied in practice.

Keywords: health promotion, health education, concept analysis, nursing

Introduction A clear conceptual framework is required as a foundation for effective nursing-related health promotion and health education research and practice (King 1994, Kulbok et al. 1997). Nearly a decade ago, Maben and Macleod Clark (1995) presented a concept analysis of health promotion in this journal. Health promotion and its influence on the nursing 2004 Blackwell Publishing Ltd

professions have developed significantly over this period. Much has occurred that now adds to Maben and Macleod Clark’s seminal paper, and consequently a further concept analysis is now needed. This is often the case, much as Maben and Macleod Clark’s concept analysis added to Brubaker’s (1983) earlier linguistic analysis of health promotion in nursing. Concept analysis, therefore, is an evolutionary process based on the notion that concepts change over time 311

D. Whitehead

(Rodgers 2000). This underpins the aim of concept analysis to move concepts towards ‘maturity’ in the context of the most recent thinking and developments (McCormack et al. 2002), and is necessary if practitioners are to be conversant with the latest developments in their health-related practices. Maben and Macleod Clark stated in 1995 that little attempt had been made up to that point in the nursing literature to clarify what the term health promotion meant. Significant steps have been taken since then to do this, as evidenced by the volume of post-1995 conceptual literature (i.e. Kulbok et al. 1997, Rush 1997, Morgan & Marsh 1998, Benson & Latter 1998, Robinson & Hill 1998, Norton 1998, Piper & Brown 1998, Whitehead 2001, 2003a). Conceptualization has been necessary for nursing, given that the terms health education and health promotion are used on a daily basis with implied meanings attached to them. Concept advancement helps to move terms away from the realm of everyday meaning towards more precise meaning and clarity (Hupcey et al. 2001). This paper draws on nursing-related and generic health promotion and health education literature to develop an up-to-date concept analysis. It does this using Morse’s (1995, 2000) and Morse et al.’s (1996a) processes of concept analysis.

The concept analysis Aim The aim of the concept analysis is to provide an up-to-date analysis of health promotion and health education that serves as a conceptual and operational foundation for clinicians and researchers.

Methodology Increasingly in the recent nursing literature, concept analysis is emerging as an important approach for exploring conceptual issues. Concept analysis is essential in nursing for three main reasons: concepts are used in theory development, analysis is required if the concept is to be operationalized into an ‘instantiation’ of the concept, and it aids practice by offering a clearer understanding of what specific terms mean (Paley 1996). Maben and Macleod Clark (1995) used the method developed by Rodgers (1989) for these purposes. I have used Morse’s methods because I believe that they are less staged, positivist and de-contextualizing than other methods and subsequently they match more closely the philosophical underpinnings of health promotion practice. Its process involves review and critical 312

appraisal of the literature in order to explore the ‘pragmatic utility’ of concepts (Morse 2000).

Literature search The extensive theoretical phase began with the collection and analysis of a broad range of health-related literature, with a focus on the interpretation contained within it. The bibliographical databases CINAHL, Medline, ASSIA and journal database EBSCO were searched for the years 1995– 2003. These databases were deemed most appropriate because they use sources that directly relate to nursing, medicine, allied health professions and health education/ health promotion practice. The key words used were ‘health promotion’ and ‘health education’, narrowed down later to include ‘health promotion theory’ and ‘health education theory’. A secondary search was conducted by investigating the reference lists of the gathered literature. Literature that sought to define health education and health promotion or provide a suitable unit of analysis was included.

Data analysis Once the literature had been collected it was analysed to investigate the level of concept maturity. If the concept contained clearly delineated and defined characteristics or preconditions it was deemed mature. This proved to be the case with the concept of health education. With the concept of health promotion, however, further analysis was needed to facilitate ‘concept clarification’, using the literature as data. This is necessary where a large body of literature exists and the concept already appears to be well described, but on closer reading the concept is often unclear and many ‘competing implicit assumptions’ are evident (Morse 1995, p. 42). Concept clarification has several stages but began in this case by posing analytical questions of the collected literature to uncover the nature of the conceptual immaturity. Areas of existing or potential conflict were then highlighted and further examined. This stage was followed by several others: ‘collapsing and combining’ analytical questions until an exhaustive list was obtained, returning to the literature to contrast these inquiries and compare congruence between different groups of literature and, finally, development of a provisional theoretical definition alongside a clear explication of the conceptual components (Hupcey et al. 2001). One of the main objectives of this concept development, therefore, was to identify and explore the concept’s defining attributes. The intended result was to achieve

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(3), 311–320

Nursing theory and concept development or analysis

‘conceptual order out of semantic chaos’ (Paley 1996, p. 573).

Findings Whereas Maben and Macleod Clark (1995) attempted to break down health promotion into the components of ‘health’ and ‘promotion’, I consider that the term is now established enough to be considered as a concept in its own right – as is the case with health education. Because it is possible to explore theoretically the paradigms of health education and health promotion in their own right, the terms can be separated from each other. It is more in line with current thinking that the paradigms may be closely related but are not inter-dependant.

Health education Theoretical definition For the most part, health education is consistently seen in the literature to have a unique and particular focus. The health education literature commonly describes it as having several functions and including actions designed to (a) impart healthrelated information that influences values, beliefs, attitudes and motivations; (b) achieve health- or illness-related learning through knowledge acquisition, assimilation and dissemination and (c) lead to skills development and lifestyle/ behaviour modification. These activities are generally targeted at the level of individuals and are identified within a framework of activities that range from information-giving through to enabling processes. Thus, health education may be defined as follows: Health education is an activity that seeks to inform the individual on the nature and causes of health/illness and that individual’s personal level of risk associated with their lifestyle-related behaviour. Health education seeks to motivate the individual to accept a process of behavioural-change through directly influencing their value, belief and attitude systems, where it is deemed that the individual is particularly at risk or has already been affected by illness/disease or disability.

Antecedents The antecedents to health education are that the individual is in need of health-related advice in order that they can make sense of their actions and behaviours and, consequently, will act on any tensions that may arise. It is assumed that an individual values and prioritizes their health as important and that it is reasonable for the health professional to act on the basis that the individual wants to avoid or reduce any negative

Health promotion and health education

health state. Health education assumes that the health professional has the necessary health-related information to impart and that the recipient is in need of and will benefit from this information. A further assumption is that if the recipient has correctly assimilated and disseminated this information, any further action on their part will involve change or modification in their behaviour. Recipients may be supported through this process, but are ultimately personally responsible for any action that they may or may not undertake. Attributes Health education information is designed to influence the knowledge-base of a client as well as their attitude, value and belief systems. This then leads to a conscious personal decision to change existing unhealthy behaviour or to avoid unhealthy behaviour in the first place. The client and health professional adopt one of two broad approaches. First, a medical approach, as a reactive and opportunistic process, may be adopted where the client has an existing condition or illness. Secondly, a preventative approach is a more proactive method adopted where the client does not have an existing condition or illness but may be at risk if they continue with or take up certain health-damaging behaviours. The attributes of health education can be summarized as: • the intention to alter/modify health-damaging behaviours where identifiable and measurable risk factors are known; • the willingness of individuals to participate in ‘expertdriven’ programmes of behavioural change in exchange for a reduction in risk of illness or disease and with the expected outcome of improved health status – usually physical. Outcomes The outcomes of health education may be positive or negative. The professional intention is that the ‘education’ will culminate in behavioural change and lead to a positive health status outcome. On the contrary, the outcome may be adverse if it is ill-conceived and demands unrealistic and unsupported outcomes that are not based on the priorities or preferences of the recipient. Successful or non-successful outcome is related to the degree to which the recipient values the change and believes that they are capable of producing it (health efficacy). The nursing-related and generic literature on health education is comparable and consistent. Its process and outcomes are systematically presented (Whitehead & Russell 2004) and the concept appears to be mature, with clear concept development and delineation. It meets the criteria for concept maturity in that the concept is labelled,


313

D. Whitehead

has a meaningful definition and has well-delineated boundaries (Morse et al. 1996b). This analysis of health education provided the basis for what is referred to as concept refinement (Hupcey 1998). This conceptual delineation and maturity, however, was not found in the health promotion literature and, according to Tones (2002), the conceptual clarification and defining of health education is a far easier and less controversial task than that for health promotion.

Health promotion Theoretical definition The recent literature stresses the socio-political nature of health promotion far more than was the case in the past. Health promotion activities are by their nature inherently politically based and driven, thus making it impossible to divorce them from the political arena. Health promotion acknowledges that individuals are not always accountable or responsible for their own health status, and that strong external elements are always in play. Broader determinants of health, such as ecological, cultural, economic and environmental factors, are known to determine the level of health of individuals and communities, and all have political underpinnings within an ‘environmental engineering’ process. The health promotion literature, over the last decade or so, has demonstrated a move from individual empowerment programmes to far more emphasis on policy-driven initiatives that work through social examination and modification, particularly at the level of collective action. Health-promoting empowerment activities are politically expedient in that they focus on the social action that promotes and leads to community empowerment, rather than just empowerment of the individual. Thus health promotion may be defined as follows: Health promotion is the process by which the ecologically-driven socio-political-economic determinants of health are addressed as they impact on individuals and the communities within which they interact. This serves to counter social inaction and social division/ inequality. It is an inherently political process that draws on health policy as a basis for social action that leads to community coalitions through shared radical consciousness. Health promotion seeks to radically transform and empower communities through involving them in activities that influence their public health – particularly via agenda setting, political lobbying and advocacy, critical consciousness-raising and social education programmes (see Whitehead 2003b). Health promotion looks to develop and reform social structures through developing participation between representative stakeholders in different sectors and agencies.

314

Antecedents The antecedent to health promotion is the premise that the health of individuals are intertwined with the collective health of the communities in which they live and by which they are served. Most individuals are powerless on their own to influence the overall health of their own communities, and therefore need to be collectively motivated, mobilised and empowered to develop political strategies in order to overcome structural dilemmas and inequalities. Health promotion is underpinned by the principles that an individual values and prioritises their and their neighbours’ health as important and that they willingly take on a representative role that facilitates community action. It recognizes that empowered communities have a much greater health impact than individuals or small groups. The role of health professionals is acknowledged, but it is assumed that their intervention is only likely to be a transitional phase, designed to provide support and set up necessary resources for community reform. Potentially, the community empowers itself politically to become selfresourcing and collectively empowered – but acknowledges that health professionals are an integral part of the community. Effective health promotion also assumes that health professionals are themselves autonomous, empowered, politically motivated and able to move freely in and out of health service arenas. Implicit within this is that health professionals understand that health promotion strategies are deeply rooted in multi-professional and multi-agency collaboration. No individual health professional or single professional body can perform health promotion on their own. Attributes Health promotion aims to support communities and their members who are affected by and wish to contribute to the socio-political, environmental and ecological determinants of health within those communities. It does so particularly through political processes such as critical consciousnessraising, agenda setting and lobbying. It draws on a range of health professionals and agencies to support and resource local community health aims, particularly through participating in social, environmental and health policy reform and encouraging its citizens to do the same. Communities are thus empowered to take on social action roles that facilitate the development of social capital as the health-related link between social structure and human agency. Social capital is ‘the total of social elements which are required for the development of human capital’ (Kritsotakis & Garmarnikow 2004, p. 44). It is tightly linked to the concepts of community networks, civic identity and engagement, reciprocity, participation, social engagement and mutual trust (Cambell et al.



1999, Hyyppa¨ & Ma¨ki 2003). It is achieved by health professionals primarily through their contribution to social and economic policy as it affects public health issues. Community empowerment, community competence and sense of community all contribute to the public health of communities (Edmondson 2003). Public health, therefore, is synonymous with health promotion in that it aims to implement co-ordinated community action to produce a healthier society. Therefore public health policy, as a cornerstone of community development, is necessarily political in order to create health-enhancing environments. The attributes of health promotion can be summarized as: • the need and desire to develop and implement communitydriven health reform based on social action, social cohesion and social capital; • the willingness of communities to become empowered and self-reliant in determining collective health needs and priorities; • the attainment of health gain as a fundamental priority and shared social objective of community action; • the active development of public health policy by communities as it applies to those communities. Outcomes Health promotion is a radical activity that promises fundamental reform of health structures within communities and society as a whole. Its outcomes can be both positive and negative. A positive outcome generally relies on the capacity and willingness of communities, and the individuals in them, to become politically and socially empowered/self-reliant, so that they can prioritize and act upon health issues based on local need. Negative outcomes occur where professionally paternalistic and disempowering health policy decisions force health-related outcomes that are irrelevant to sustained community development and are not based on or resourced according to the social reality of that community. Furthermore, there is potential for communities to become introspective and insular as they seek to protect their hard-earned gains, to the exclusion of neighbouring communities and the population as a whole.

Discussion It is important that health professionals are able to define theoretically and delineate exactly what constitutes both health education and health promotion practice. Effective health promotion and health education practices are dependent on sound theory (Caplan & Holland 1990). Clear conceptualization acts as a base-line to validate current practice and serves as a springboard for innovation and


advancement. Morgan and Marsh (1998) state that, although the concept of health promotion in nursing has evolved, its definition still remains too broad. Therefore, it is necessary to identify how the current literature defines today’s health promotion against that of past definitions. For instance, what Maben and Macleod Clark (1995) and Benson and Latter (1998) refer to as a traditional approach and a new paradigm approach to health promotion have become redundant. Similarly, Kulbok et al. (1997) use the term behavioural health promotion to denote a supposedly new paradigm approach. These authors refer to approaches that involve individualistic and behaviourally-orientated ‘empowerment’ as the mainstay of health promotion. Particularly at a political level, however, Robinson and Hill (1998) argue that this individualistic orientation is a major obstacle to current nursing-related health promotion practice. To continue using the label ‘new paradigm’ to describe health promotion in nursing would necessitate that we now acknowledge a ‘newer’ paradigm approach to denote the emergence of a far more politically-orientated empowering health promotion paradigm. This is especially so because health-promoting empowerment approaches are often misconstrued within the nursing literature. MacDonald (1998) argues that most health professionals are not in a position to empower clients and instead are only in a position to offer impowerment. In this context, empowerment is facilitated through a client’s own endeavours without reference to an authority, while impowerment is power conferred on clients by someone in authority. To compound the health promotion empowerment issue in nursing, some of the current literature disputes the place of behavioural/individual empowerment as a valid form of health promotion. It states that these activities are instead properties of ‘progressive’ health education activity. Piper and Brown (1998) make this distinction in referring to the Patient Information Model to denote a limited form of health education, as compared with the Patient Empowerment Model that addresses a less limited and more enabling type of health education. Empowerment, in current health promotion terms, means moving away from an individual and behavioural orientation towards more collective community-based action. It is primarily concerned with empowering citizens to take control of their health through methods such as community development, political advocacy, formulating integrated health strategies and social marketing (Webster & French 2002). Of course, this does not preclude individual empowerment strategies or fail to acknowledge their usefulness, but makes the crucial distinction between individual and community empowerment. According to Wallerstein (1992, p. 200), health promotion empowerment is:


315

D. Whitehead A social-action process that promotes participation of people, organisations and communities towards the goals of increased individual and community control, political efficacy, improved quality of life and social justice.

While empowered individuals may at first be needed to mobilize communities, an empowered community generates norms and support systems that enable individuals in greater numbers to acquire the competencies and characteristics of self-empowerment (Tones 2001). In effect, this suggests that a better strategy for empowering more individuals lies not with individual empowerment programmes, but with the filtering-down process that accompanies a whole community action empowerment strategy. The World Health Organization (WHO) has attempted to move the definition of health promotion away from a medical/preventative focus and towards the health and wellbeing of whole populations, so that the citizens of local communities politically control the determinants of health that are relevant to them (WHO 1984, 1986). Central to the tenet of health promotion as a developing ideology are the politically-driven processes of the ‘new’ public health movement (Macdonald & Bunton 2002). Once seen as competing and different concepts, public health has more recently allied itself to health promotion to the extent that politically, economically and socially they are almost indistinguishable from each other – or that public health is essentially a sub-set of health promotion (public health promotion) (Oakley & Oliver 2001, Webster & French 2002). Harrison (2002) suggests that it is no longer tenable to separate the disciplines of health promotion and public health where a wider agenda of sustainable human development applies. While many of the earlier conceptual nursing articles mention socio-political and community processes, they do so as add-ons and mainly refer to socio-political processes as ‘health promotion at its broadest level’. Socio-political process, however, is fundamental to all current health promotion activity. Subsequently, a huge amount of nursing literature has recently emerged that stresses the healthpromotional socio-political role of nurses in relation to health policy and public health processes. (e.g. Antrobus & Kitson 1999, Falk Rafael 1999, Gebbie et al. 2000, Spurgeon 2000, Scott & West 2001, Des Jardin 2001, Whitehead 2003b). This emphasis is also the case in relation to nursing education (i.e. Callaghan 2000, Conger & Johnson 2000, Clifford 2000, Cohen & Milone-Nuzzo 2001, Liimatainen et al. 2001, Whitehead 2002, 2003c). Fourteen years ago, Tones (1990) argued that lobbying and advocacy for political change should be the main focus of health promotion, and this has now happened. Activities that

316

do not include politically-orientated empowerment strategies may not now be categorized as health promotion (Macdonald & Davies 1998, Tones 2000). According to Jones and Douglas (2000), the more recent emphasis on health promotion as a radical socio-political process has been ‘striking’. The majority of current health promotion literature stresses its socio-political contribution over any other aspect (Jones 1997, Whitelaw et al. 1997, MacDonald 1998, Tones 2001, Tones & Tilford 2001, Harrison 2002). Health promotion is in itself a political process. It is a radical activity that poses fundamental questions about the way that society is organized and how this directly impacts on the health of populations (Victor 1995). As Harrison (2002, pp. 164–165) suggests: …population health is really an outcome of ‘emergent capacity’ arising from the effects of health-related social, economic and cultural activity and investment…(it) requires concerted, sophisticated and integrated political action to bring about change and requires professionals concerned with public health to engage with the politics of systems and organisations…

Therefore, health promotion is currently represented mainly by activities that build healthy public policy and strengthen community action in order to achieve social cohesion and capital. The goal of health promotion is thus the facilitation of concerted social empowerment that creates ‘full and organised community participation and ultimate self-reliance’ (Yeo 1993, p. 233). McMurray (1999, p. 262) indicates that the most significant shift in conceptualization and emphasis in health promotion has been: …from teaching people how to manage their health [individual/ behavioural orientation] to a more socially embedded approach that capitalises on the inherent capacity of community members to establish their own goals, strategies and priorities for health…a socioecological, community development approach to community health.

Rawson (2002) confirms that socio-politically-oriented community development approaches are the most ‘authentic’ or ‘ideal’ form of health promotion practice. Furthermore, health promotion strategies acknowledge differing forms of community. For instance, the ‘global community’ seeks to develop progressive social change via an credible international public health agenda (Harrison 2002) and find relevant political answers to problems such as new diseases (i.e. SARS, HIV), the impact of wars and other humanitarian disasters. To clarify further the points made in the last few paragraphs I refer to the fact that, according to Ewles and



Simnett (1999), there are five distinct approaches to healthrelated practice. For the sake of conceptual clarity I have adapted these approaches and refer to them as medical, preventative, educational, empowerment and socio-political. In the case of this concept analysis, I argue that the literature now tends to refer to medical and preventative approaches as most likely to fall within the ambit of health education, while empowerment and socio-political activities are more commonly termed health promotion. This suggests that certain health-related approaches sit in the closely related yet independent paradigms of health education and health promotion. This aids delineation of the concepts. If most nursing health-related programmes come under the auspices of a medical or preventative approach, then clearly they constitute health education and not health promotion. Alternatively, any nursing activity that involves ecologicallyand environmentally-driven action and community-based empowerment would correctly be termed health promotion. This analogy leaves the educational approach somewhere in the middle, serving as an enabling/individual ‘impowerment’ process that bridges the gap between the two paradigms and demonstrates their inter-relatedness (Whitehead 2003a). The extent to which the educational approach sits more closely with either health education or health promotion will depend on the degree to which it is structured to facilitate individual enablement or community-based empowerment. The educational approach is perhaps most realistic for the majority of nurses to strive for, given the constraints of health service settings. It is an approach that could also serves as a useful catalyst for initiating and driving future community-empowerment and socio-political health promotion practice. However, individual health education interventions may complement, but do not constitute, the collective action that underpins health promotion (Piper & Brown 1998). Therefore, social action may involve elements of education but it is essentially a radical political process (French 1990). I acknowledge that providing a ‘final’ definition of health promotion is an impossible task. To demand conceptual clarity within all of the health promotion/health education literature is somewhat naı¨ve. The ‘exact’ point of demarcation may not be clear. For instance, at what point does a wide-ranging health education strategy that may involve elements of empowerment or political process cease to be health education and become health promotion and vice versa? The operationalization of concepts is difficult because it is unlikely that there is ever going to be only one theory for whatever is being investigated – therefore to demand universal agreement is ‘unreasonable’ (Paley 1996). To leave a concept wide open so that it is used as an interchangeable


‘catch all’ term, however, is highly problematical – especially in the case of health promotion.

Conclusions A current concept analysis is only the starting point for concerted health promotion reform in nursing. A clear concept of health promotion, and for that matter health education, must subsequently be followed up with a concerted effort to implement effective programmes in nursing practice. Despite a clearer theoretical definition of health promotion, there is still very little nursing work that is credibly linked to health promotion strategies directly impacting socio-politically on communities (see, for example, Choudhry et al. 2000, Huyhn et al. 2000, Westbrook & Schultz 2000, Kraus et al. 2003). This is not to say that nurses are not involved in radical health promotion programmes, but where they are they may not be initiating, evaluating or clearly disseminating these activities. For instance, Graney (2002) states that the individualistic orientation of community-based nurses still fails to recognize the importance of community health-oriented health promotion activities. Also, Dalziel (2002, p. 220) argues that what is missing from primary care is the ‘action part’ of community development because collective action is still ‘scary’ for nurses in this setting. Anderson et al. (2002) offer a theoretical model that addresses these issues. Therefore, current health promotion strategies require not just a different mindset, but also a different way of working. The shift that is required is highlighted by Harrison (2002, p. 175): The health development professions [including nurses] must ally themselves with civic society in the development of systems of health governance at each level of social and economic administration. They must network their knowledge and skills across all levels, systems, sectors and professions. They must politically intervene within the ‘social machinery’ of the state and within all forms of social organisation and systems where decisions are made and resources allocated. They must join in the wider social project of sustainable human development at every level, from local to global.

Trying to define current theoretical frameworks for health promotion, as in this paper, is vital. Rawson (2002, p. 267) suggests that ‘the asking will help better define the subject matter and create the discipline to discover the true potential of health promotion’, while French (1990, p. 12) states: This is not simply a matter of semantic refinement; what is at stake is the very practice of health promotion and the positions it adopts based on a particular view of the world.


317

D. Whitehead

References

What is already known about this topic • Linguistic and concept analyses of health promotion in nursing have been developed, the first over two decades ago and the second nearly a decade ago. • ‘Health promotion’ is based on political and community empowerment-driven processes, whereas ‘health education’ has remained unchanged for many decades and emphasizes individual and behaviourally focused activities.

What this paper adds • Further conceptual clarity based on existing interdisciplinary theoretical definitions and usage, reflecting the theoretical basis and maturity of health promotion and health education. • An up-to-date conceptual and operational foundation for clinicians, theorists and researchers. • The concept of health promotion cannot be fully understood and acted upon without an accompanying concept analysis of health education that distinguishes between the two. • The importance of nurses working collaboratively to influence the socio-political determinants of social action, cohesion and capital in the communities they serve. Whitelaw et al. (1997) also suggest that health promotion is not only judged on its actions but also on its capacity to develop an appropriate theoretical agenda. To bring about broad health promotion reform, a radical ‘refocusing upstream’ is required that generates social and political activism in nursing. This necessitates that nurse’s step outside traditional roles and boundaries in order to adopt broader health promotion roles. It requires a mobilization of appropriate strategies that bring about measurable organizational and community change – such as employing participatory action research activities (Flynn et al. 1994, Tones 2000, Clark et al. 2003, Whitehead et al. 2003). Nurses also need to make inroads into unfamiliar territories if they wish to engage in wide-ranging health promotion reform, such as influencing media advocacy initiatives as a means of critical consciousness-raising for political change (Chapman & Lupton 1994, Holder & Treno 1997, Whitehead 2000, Stead et al. 2002). These activities can sit within and alongside traditional, yet valid, individual empowerment programmes. This said, what the future holds for health promotion in nursing seems clear – it is the advancement of a socio-politically-oriented and community-driven social capital agenda. 318

Anderson D., Guthrie T. & Schirle R. (2002) A nursing model of community organisation for change. Public Health Nursing 19, 40–46. Antrobus S. & Kitson A. (1999) Nursing leadership: influencing and shaping health policy and nursing practice. Journal of Advanced Nursing 29, 746–753. Benson A. & Latter S. (1998) Implementing health promoting nursing: the integration of interpersonal skills and health promotion. Journal of Advanced Nursing 27, 100–107. Brubaker B. (1983) Health promotion: a linguistic analysis. Advances in Nursing Science 5, 1–14. Callaghan S. (2000) Incorporating a political action framework into a BSN programme. Journal of Nursing Education 33, 34. Cambell C., Wood R. & Kelly M.K. (1999) Social Capital and Health. Health Education Authority, London. Caplan R. & Holland R. (1990) Rethinking health education theory. Health Education Journal 49(1), 10–12. Chapman S. & Lupton D. (1994) The Fight for Public Health: Principles and Practice of Media Advocacy. BMJ Publishing Group, London. Clark M.J., Cary S., Diemert G., Ceballos R., Sifuentes M., Atteberry I., Vue F. & Trieu S. (2003) Involving communities in community assessment. Public Health Nursing 20, 456–463. Clifford C. (2000) International politics and nursing education: power and control. Nurse Education Today 20, 4–9. Cohen S.S. & Milone-Nuzzo P. (2001) Advancing health policy in nursing education through service learning. Advances in Nursing Science 23 28–40. Conger C.O. & Johnson P. (2000) Integrating political involvement and nursing education. Nurse Educator 25, 99–103. Choudhry U.K., Jandu S., Mahal J., Singh R., Sohi-Pabla H. & Mutta B. (2000) Health promotion and participatory action research with South Asian women. Journal of Nursing Scholarship 34, 75–81. Dalziel Y. (2002) Community development as a public health function. In Public Health in Policy and Practice (Cowley S., ed.), Bailliere Tindall, Edinburgh, pp. 217–238. Des Jardin K. (2001) Political involvement in nursing – politics, ethics, and strategic action. AORN Journal 74(5), 613–630. Edmondson R. (2003) Social capital: a strategy for enhancing health? Social Science & Medicine 57, 1723–1733. Ewles L. & Simnett I. (1999) Promoting Health: A Practical Guide, 4th edn. Bailliere Tindall, Edinburgh. Falk Rafael A. (1999) The politics of health promotion: influences on public health nursing practice in Ontario, Canada from Nightingale to the nineties. Advances in Nursing Science 22(1), 23–39. Flynn B., Ray D. & Ryder M. (1994) Empowering communities: action research through healthy cities. Health Education Quarterly 2, 395–405. French J. (1990) Boundaries and horizons, the role of health education within health promotion. Health Education Journal 49(1), 7–9. Graney A. (2002) Effectiveness and community empowerment. In Public Health in Policy and Practice (Cowley S., ed.), Bailliere Tindall, Edinburgh, pp. 164–187. Gebbie K.M., Wakefield M. & Kerfoot K. (2000) Nursing and health policy. Journal of Nursing Scholarship 32(3), 307–315.


Nursing theory and concept development or analysis Harrison D. (2002) Health promotion and politics. In Health Promotion: Disciplines, Diversity and Developments, 2nd edn (Bunton R. & Macdonald G., eds), Routledge, London, pp. 158– 177. Holder H.D. & Treno A.J. (1997) Media advocacy in community prevention: news as a means to advance policy change. Addiction 92(1), 189–200. Hupcey J.E. (1998) Social support: assessing conceptual coherence. Qualitative Health Research 8(3), 304–318. Hupcey J.E., Penrod J., Morse J.M. & Mitcham C. (2001) An exploration and advancement of the concept of trust. Journal of Advanced Nursing 36(2), 282–293. Huyhn K., Kosmyna B., Lea H., Munch K.R., Reynolds H.E., Specht C., Tinker E.C., Yee A.J. & French L.R. (2000) Creating an adolescent health promotion INTERNET.SITE: A community partnership between university nursing students and an inner-city High School. Nursing and Health Care Perspectives 21(3), 122– 126. Hyyppa¨ M.T. & Ma¨ki J. (2003) Social participation and health in a community rich in stock of social capital. Health Education Research 18, 770–779. Jones L. (1997) The politics of health promotion. In The Challenge of Promoting Health: Exploration and Action (Jones L. & Sidell M., eds), Macmillan, London. pp. 131–157. Jones L. & Douglas J. (2000) The rise of health promotion. In Promoting Health: Knowledge and Practice, 4th edn (Katz J., Peberdy A. & Douglas J., eds), The Open University, London, pp. 58–79. King P.M. (1994) Health promotion: the emerging frontier in nursing. Journal of Advanced Nursing 20, 209–218. Kraus M.B., Morgan C.M & Matteson P.S. (2003) ‘‘Razoo Health’’: a community-based nursing education initiative. Journal of Nursing Education 42, 304–310. Kritsotakis G. & Garmarnikow E. (2004) What is social capital and how does it relate to health? International Journal of Nursing Studies 41, 43–50. Kulbok P.A., Baldwin J.H., Cox C.L. & Duffy R. (1997) Advancing discourse on health promotion: beyond mainstream thinking. Advances in Nursing Science 20(1), 12–20. Liimatainen L., Poskiparta M., Sjogren A., Kettunen T. & Karhila P. (2001) Investigating student nurses’ constructions of health promotion in nursing education. Health Education Research 16(1), 33–48. Maben J. & Macleod Clark J. (1995) Health promotion: a concept analysis. Journal of Advanced Nursing 22(6), 1158–1165. MacDonald T.H. (1998) Rethinking Health Promotion: A Global Approach. Routledge, London. Macdonald G. & Davies J. (1998) Reflection and vision: proving and improving the promotion of health. In Quality, Evidence and Effectiveness in Health Promotion: Striving for Certainties (Davies J. & Macdonald G., eds), Rout ledge, London, pp. 5–18. Macdonald G. & Bunton R. (2002) Health promotion: disciplinary developments. In Health Promotion: Disciplines, Diversity and Developments, 2nd edn (Bunton R. & Macdonald G., eds), Routle dge, London, pp. 9–27. McCormack B., Kitson A., Harvey G., Rycroft-Malone J., Titchen A. & Seers K. (2002) Getting research into practice: the meaning of ‘context’. Journal of Advanced Nursing 38(1), 94–104

Health promotion and health education McMurray A. (1999) Community Health and Wellness: A Sociological Approach. Harcourt, Sydney. Morgan I.S. & Marsh G.W. (1998) Historic and future health promotion contexts for nursing. Image – Journal of Nursing Scholarship 30(4), 379–383. Morse J.M. (1995) Exploring the theoretical basis of nursing using advanced techniques of concept analysis. Advances in Nursing Science 17(3), 31–46. Morse J.M. (2000) Exploring pragmatic utility: concept analysis by critically appraising the literature. In Concept Development in Nursing: Foundations, techniques, and Applications, 2nd edn (Rodgers B.L. & Knafl K.A., eds), W.B. Saunders, Philadelphia, pp. 333–352. Morse J.M., Hupcey J.E. & Mitcham C. & Lenz E. (1996a) Concept analysis in nursing research: a critical appraisal. Scholarly Inquiry for Nursing Practice 10, 253–277. Morse J., Mitcham C., Hupcey J. & Tason M. (1996b) Criteria for concept analysis. Journal of Advanced Nursing 24, 385–390. Norton L. (1998) Health promotion and health education: what role should the nurse adopt in practice? Journal of Advanced Nursing 28, 1269–1275. Oakley A. & Oliver S. (2001) Looking to the future: policies and opportunities for better health. In Using Research for Effective Health Promotion (Oliver S. & Peersman G., eds), Open University Press, Buckingham, pp. 180–191 Paley J. (1996) How not to clarify concepts in nursing. Journal of Advanced Nursing 24, 572–578. Piper S.M. & Brown P.A. (1998) The theory and practice of health education applied to nursing: a bi-polar approach. Journal of Advanced Nursing 27, 383–389. Rawson D. (2002) Health promotion theory and its rationale construction: lessons from the philosophy of science. In Health Promotion: Disciplines, Diversity and Developments, 2nd edn (Bunton R. & Macdonald G., eds), Routledge, London, pp. 249– 270. Robinson S. & Hill Y. (1998) The health promoting nurse. Journal of Clinical Nursing 7, 232–238. Rodgers B.L. (1989) Concepts, analysis, and the development of nursing knowledge: the evolutionary cycle. Journal of Advanced Nursing 14, 330–335. Rodgers B.L. (2000) Concept analysis: an evolutionary view. In Concept Development in Nursing: Foundations, Techniques and Applications, 2nd edn (Rodgers B.L. & Knafl K.A., eds), W.B. Saunders, Philadelphia, pp. 77–102. Rush K.L. (1997) Health promotion ideology and nursing education. Journal of Advanced Nursing 25(6), 1292–1298. Scott C. & West E. (2001) Nursing in the public sphere: health policy research in a changing world. Journal of Advanced Nursing 33, 387–395. Spurgeon P. (2000) Implications of policy development for the nursing profession. In Health Policy and Nursing: Influence, Development and Impact (Hennessey D. & Spurgeon P., eds), MacMillan, London, pp. 190–200. Stead M., Hastings G. & Eadie D. (2002) The challenge of evaluating complex interventions: a framework for evaluating media advocacy. Health Education Research 17(3), 351–364. Tones K. (1990) Why theorise? Ideology in health promotion. Health Education Journal 49(1), 2–6.


319

D. Whitehead Tones K. (2000) Evaluating health promotion: a tale of three errors. Patient Education and Counseling 39, 227–236. Tones K. (2001) Health promotion: the empowerment imperative. In Health Promotion: Professional Perspectives, 2nd edn (Scriven A. & Orme J., eds), Palgrave, Basingstoke Hampshire, pp. 3–18. Tones K. (2002) Reveille for Radicals! The paramount purpose of health education. Health Education Research 17(1), 1–5. Tones K. & Tilford S. (2001) Health Promotion: Effectiveness, Efficiency and Equity, 3rd edn. Nelson Thornes, London. Victor C. (1995) Inequalities in health and health promotion. In Health Promotion for All (Pike S. & Forster D., eds), Churchill Livingstone, Edinburgh, pp. 157–170. Wallerstein N. (1992) Powerlessness, empowerment and health. Implications for health promotion programmes. American Journal of Health Promotion 6, 197–205. Webster C. & French J. (2002) The cycle of conflict: the history of the public health and health promotion movements. In Promoting Health: Politics & Practice (Adams L., Amos M. & Munro J., eds), Sage Publications, London, pp. 5–12. Westbrook L.O. & Schultz P.R. (2000) From theory to practice: community health nursing in a public health neighbourhood team. Advances in Nursing Science 23(2), 50–61. Whitehead D. (2000) Using mass media within health promotion practice: a nursing perspective. Journal of Advanced Nursing 32, 807–816. Whitehead D. (2001) Health education, behavioural change and social psychology: nursing’s contribution to health promotion? Journal of Advanced Nursing 34, 822–832.

320

Whitehead D. (2002) The health promotional role of a pre-registration student cohort in the UK: a grounded theory study. Nurse Education in Practice 2, 197–207. Whitehead D. (2003a) Viewing health promotion and health education as symbiotic paradigms: bridging the theory and practice gap between them. Journal of Clinical Nursing 12, 796– 805. Whitehead D. (2003b) Incorporating socio-political health promotion activities in clinical practice. Journal of Clinical Nursing 12, 668–677. Whitehead D. (2003c) The health-promoting nurse as a health policy career expert and entrepreneur. Nurse Education Today 23, 585– 592. Whitehead D., Taket A. & Smith P. (2003) Action research in health promotion. Health Education Journal 62(1), 5–22. Whitehead D. & Russell G. (2004) How effective are health education programmes – resistance, reactance, rationality and risk? Recommendations for effective practice. International Journal of Nursing Studies 41, 163–172. Whitelaw S., McKeown K. & Williams J. (1997) Global health promotion models: enlightenment or entrapment? Health Education Research 12(4), 479–490. World Health Organisation (1984) Health Promotion: A Discussion Document on Concepts and Principles. WHO, Geneva. World Health Organisation (1986) The Ottawa Charter for Health Promotion. WHO, Geneva. Yeo M. (1993) Toward an ethic of empowerment for health promotion. Health Promotion International 8(3), 225–235.
